on 09-Aug-2017 (Wed)

Guidelines recommend upper endoscopy for patients with dyspepsia and alarm features. Alarm features include onset after age 50 years; anemia; dysphagia; odynophagia; vomiting; weight loss; family history of upper gastrointestinal malignancy; personal history of peptic ulcer disease, gastric surgery, or gastrointestinal malignancy; and abdominal mass or lymphadenopathy on examination

For patients younger than 50 years without alarm features, a test-and-treat approach for Helicobacter pylori is reasonable and cost effective when the patient is from an area where the prevalence of H. pylori is high (such as developing countries).

proton pump inhibitor is the most appropriate first-line strategy if the patient is from an area where the prevalence of H. pylori is low.

An empiric trial of omeprazole would not be appropriate because it may mask a gastric ulcer or cancer.

Eighty percent of patients with primary sclerosing cholangitis have ulcerative colitis.

Primary sclerosing cholangitis (PSC) is diagnosed by measuring liver enzymes and performing cholangiography. Serum alkaline phosphatase values are 3 to 10 times the upper limit of normal, and serum alanine aminotransferase and aspartate aminotransferase levels are two to three times the upper limit of normal. Serum total bilirubin levels may be normal in 60% of patients. Serum antinuclear and anti-smooth muscle antibodies are present in 20% to 50% of patients, but antimitochondrial antibodies are rarely found in PSC

The gold standard for diagnosis of PSC is cholangiography. Diagnostic findings consist of segmental bile duct fibrosis with saccular dilatation of normal intervening areas, resulting in the characteristic “beads on a string” appearance. Magnetic resonance cholangiopancreatography (MRCP) has been increasingly used and has an overall diagnostic accuracy rate of 90%.

Patients with PSC and ulcerative colitis are at increased risk for colon cancer and should receive surveillance. There is no effective medical therapy for PSC

PSC is generally a progressive disease that often requires liver transplantation.

Liver biopsy is usually not necessary for the diagnosis of PSC. Liver biopsy is required for making a diagnosis of small-duct PSC when cholangiography is normal.

It is therefore implausible to designate one type of discourse as being primary and the other type as being secondary when both types fulfill the same kind of communicative functions

Periductal fibrosis with inflammation, bile duct proliferation, and ductopenia are the main histologic findings

IgG4-associated cholangitis may mimic PSC, but patients will usually have abnormalities in the pancreas on cross-sectional imaging.

High-risk ulcers are characterized by active arterial spurting or a nonbleeding visible vessel; they should be treated endoscopically with hemostatic clips, thermal therapy, or injection of sclerosants

An ulcer with a visible vessel has an approximately 50% risk of rebleeding if not treated endoscopically.

Clean-based ulcers rebleed in less than 5% of cases and do not require endoscopic therapy

Octreotide may have a marginal benefit by decreasing the rate of nonvariceal bleeding, but it is inferior to intravenous proton pump inhibitors. Octreotide is most useful in patients with variceal bleeding

Acute kidney injury occurs in approximately 20% of hospitalized patients with cirrhosis; such patients should receive a fluid challenge (usually with 25% albumin) to evaluate fluid responsiveness before hepatorenal syndrome can be diagnosed.

In approximately 70% of patients with cirrhosis and AKI, the precipitant is prerenal, from sources such as infection, gastrointestinal bleeding, excessive diuresis, or diarrhea.

HRS diagnostic criteria consist of (1) an increase in the serum creatinine level to greater than 1.5 g/dL (132.6 µmol/L) over days to weeks, (2) lack of response to an albumin challenge of 1 g/kg/d for 2 days, and (3) the absence of shock, nephrotoxic drugs, active urine sediment, proteinuria greater than 500 mg/d, and ultrasound evidence of parenchymal kidney disease or obstruction.

Norepinephrine with albumin infusion is effective for patients with type 1 HRS who are in the ICU.

Midodrine, octreotide, and albumin are the appropriate treatments for type 1 HRS in patients outside of the ICU.

Terlipressin is effective for type 1 HRS

Patients with cholangitis should receive immediate broad-spectrum antimicrobial therapy; if rapid improvement is not seen, urgent endoscopic stone removal should be performed.

The presence of fever, abdominal pain, and jaundice (Charcot triad) is consistent with acute cholangitis, and ERCP is indicated

Acute cholangitis is usually caused by Escherichia coli, Klebsiella species, Pseudomonas species, and enterococci and can progress to septic shock with or without liver abscess formation.

Percutaneous cholecystostomy could be considered if this patient had acute cholecystitis

Findings of gallbladder inflammation may include thickening of the gallbladder wall (>2 mm), intramural gas, and pericholecystic fluid

Risk factors for NSAID-related gastrointestinal complications include a history of peptic ulcer disease or other gastrointestinal bleeding event; Helicobacter pyloriinfection; age 65 years or older; concomitant use of aspirin (of any dose), anticoagulants, other NSAIDs, or glucocorticoids; high-dose NSAID use; and chronic comorbid illness.

Changing this patient's aspirin to an enteric-coated formulation will not reduce the risk of NSAID-induced gastrointestinal injury.

Common criteria for diagnosis of chronic pancreatitis consist of clinical features (pain, recurrent attacks of pancreatitis, weight loss) with objective findings of steatorrhea and pancreatic calcifications.

The most appropriate treatment for chronic pancreatitis is pancreatic enzymes

Serologic testing for tissue transglutaminase antibodies should be performed in patients with suspected celiac disease, which may present with weight loss, steatorrhea, and nutritional deficiencies.

IgA tissue transglutaminase antibody is the screening test of choice for celiac disease and is both sensitive and specific; initial testing for celiac disease should be done while the patient is consuming gluten

anti–Saccharomyces cerevisiae antibodies (ASCA) have been proposed as a serologic method for differentiating Crohn disease from ulcerative colitis, they are neither adequately sensitive nor specific and can lead to false-positive results if used as a screening test for gastrointestinal symptoms.

Upper endoscopy with small-bowel biopsies is performed in patients with a consistent clinical picture and positive serologic studies to confirm the diagnosis of celiac disease. Characteristic biopsy findings include intraepithelial lymphocytosis, crypt hyperplasia, and villous blunting.

Routine complete blood count, serum chemistry studies, thyroid function studies, stool studies for ova and parasites, and abdominal imaging are unnecessary in establishing the diagnosis of irritable bowel syndrome

The American College of Gastroenterology recommends a simple definition of IBS: abdominal pain or discomfort that occurs in association with altered bowel habits over a period of at least 3 months. The diagnosis of IBS is further subtyped into diarrhea predominant (IBS-D), constipation predominant (IBS-C), or mixed (IBS-M), which alternates between diarrhea and constipation

The passage of mucus is commonly reported in IBS, so this symptom alone does not warrant colonoscopy.

Before pursuing Helicobacter pylori eradication therapy, noninvasive testing for H. pylorishould be performed to confirm infection.

Noninvasive H. pylori testing modalities include serology, the fecal antigen test, or the urea breath test.

Serologic testing for H. pylori has limitations in that it does not test for active H. pylori infection and has poor positive predictive value.

Fecal antigen testing and urea breath testing offer a more accurate means of noninvasive testing for H. pylori, as both of these test modalities assess for the presence of active infection.

Empiric treatment for H. pylori is not appropriate because the diagnosis of H. pylori should be made before initiating treatment.

Upper endoscopy would be appropriate for patients whose symptoms do not respond to H. pylori treatment or PPI therapy. Patients older than 50 years or with alarm features should be evaluated with upper endoscopy.

Wilson disease should be considered in all patients younger than 40 years of age who have unexplained liver disease.

Young patients with Wilson disease tend to present with acute liver failure; older patients present with chronic liver disease and/or neurologic manifestations.

When Wilson disease causes acute hepatitis, usually in young patients, the sudden release of copper from liver cells can also induce hemolytic anemia